Maintenance Culture Matters
Chris and Fred discuss how important maintenance culture is – especially when it comes to safety-critical systems. Like ‘cable cars’ used to transport people up ski slopes. But unfortunately (like the recent accident that occurred in Italy that resulted in 14 deaths) toxic maintenance culture can lead to disastrous consequences. And this tends to happen across the world on a regular basis. Why does this happen?
Join Chris and Fred as they discuss the recent cable car accident that occurred in Italy where 14 people died and how this relates to maintenance culture.
- So what happened? As the cable car was reaching the top of the ski slope, a ‘thinner moving’ cable snapped, meaning that it accelerated back down a ‘thicker static’ cable that acts as a ‘rail’ for the cable car. The cable car quickly accelerated to 100 km per hour or 60 miles per hour and flew off the cable, into the ground, killing all but one on board.
- So what went wrong? An emergency brake that is designed to arrest the movement of the cable car if it goes too fast was deliberately disabled. It was intermittently applying when it shouldn’t, so a technician inserted a ‘steel staple’ to hold the emergency brake open.
- Was it the technician’s fault? According to his lawyer …
He is not a criminal and would never have let people go up with the braking system blocked had he known that there was even a possibility that the cable would have broken. He can’t even begin to get his head around the fact that the cable broke.
- What does this say about culture? The term ‘plausible deniability’ might be fitting here. The technician’s supervisors claim they didn’t know about the emergency brake being disabled. But … why did the technician believe that disabling the emergency brake was even an option? The emergency brake was included in the design of the cable car (at some cost). How can we, as engineers, believe that an emergency component that was included in the design is superfluous to requirements? We all know of organizations where bypassing safety elements of a design feature is fundamentally unacceptable.
- What does weak management look like? For example, a manager who deliberately over allocates tasks to subordinates, knowing that they can’t possibly complete them all, but thinking they have avoided accountability for these tasks not being done. We can only speculate here, but we as a community have some experience in this regard. Safety is a special beast and needs to be ingrained in behaviors. Or culture. Some organizations empower every employee to push a hypothetical ’emergency stop’ button if they see a problem. In fact, they encourage it. Identifying a problem early allows a fast and inexpensive remedy. Other organizations discourage that ’emergency stop’ button from being pressed because it is all about throughput or profit.
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